=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205203692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEWLIFE COUNSELING AND CONSULTATION, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 09/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17105 KENTON DR SUITE 205C
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-5653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-727-6297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17105 KENTON DR SUITE 205C
-----------------------------------------------------
City | CORNELIUS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28031-5653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-727-6297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. ANDREA L HAYWARD
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 704-727-6297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C009419
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------